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Atrial AVM: Transfalcine Approach

January 13, 2016


Here's another case of a trigonal arteriovenous malformations, resected via the posterior interhemispheric contralateral transfalcine transprecuneus approach. This is a 22 year old male who presented with known history of arteriovenous malformation considered inoperable at an outside institution related to his history of intraventricular hemorrhage. Due to his young age, I believe that resection is indicated to avoid the future risk of hemorrhage. The morphology of them affirmation is quite peculiar, it is primarily located intraventricular within the trigon It does affect the medial wall of the ventricle. And one of the primary and predominant source of feeding to the malformation is via the PCA. You can also see that this AVM is relatively high flow with the drainage into the vein of Galen. This patient underwent his procedure in the lateral position, with the right side or the unaffected site down. A lumbar drain was used. A craniotomy on roof this precentral sinus. You can see this precentral sinus, here's anterior, here's posterior. Here's the falx, lumbar CSF drainage was quite effective here. Here's the junction of the falx and tentorium. Fluorescein angiography demonstrates the location, of this straight sinus. The T-shaped incision within the falx was completed. Here's the limb of the T-shaped incision. You can see our location based on our navigation. This illustration again demonstrates the principles of the transfalcine approach, discussed in our other videos. Again the, false and flaps mobilize using retention sutures. Two sutures inferior to this procedural sinus to mobilize the super sutural sinus. And again the transcortical trajectory through a cross-court contralateral operative corridor toward the medial wall of the trigon or atrium Here, you can see some of the arteriolized-veins originating from the contralateral medial hemisphere, joining their straight sinus. Here's the dissection along the circumference of the malformation. Some of the cortical feeding vessels are disconnected early. Here you can see again the arteriolized-veins. Interhemispherically here, is the atrium of the lateral ventricle that was entered early. All the feeding vessels including the ones along the splenium are disconnected. The draining vein is protected early on in our resection. Here's disconnection of the AVM from the walls of the atrium and the choroid plexus. Obviously the advantages of this approach are numerous, including early identification of the ventricular walls, draining veins and the choroid plexus. Here's the operative trajectory. Post-operative angiogram demonstrated crostal resection of the malformation. unfortunately, this patient suffered from some visual decline, related to thrombosis of his distal section of the posterior cerebral artery. I do believe that this was related to a retrograde thrombosis after some of the distal branches of the PCA, feeding the malformation were disconnected. Thank you.

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